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Anteroposterior (A) view of the hand and lateral (B) view of the middle finger. The patient reported swelling, but no inflammation or tenderness was found.

AAOS Now

Published 4/1/2010

What’s your Diagnosis?

In this feature, AAOS Now publishes a series of images, challenging readers to diagnose the condition depicted. Last month, Stephen A. Albanese, MD, and E. Mark Levinsohn, MD, provided a set of radiographs and the following patient information:

“The patient is a 67-year-old, healthy male who complained of swelling of the middle finger. Upon examination, no inflammation or tenderness was found. Radiographs (anteroposterior and lateral views) of the hand were taken and are shown here.”

Readers proposed various diagnoses. Robert Harway, MD, suggested a nonossifying fibroma. He noted that primary malignancies in the hand are relatively rare, and that the joint was not violated.

Anteroposterior (A) view of the hand and lateral (B) view of the middle finger. The patient reported swelling, but no inflammation or tenderness was found.

Heidi C. Shors, MD, wrote, “I would be concerned for Paget’s, fibrous dysplasia, or a calcium/parathyroid disorder, although many of these can involve more than one bone.” She suggested screening for other sites, a calcium/parathyroid work-up, and a biopsy.

Scott Helmers, MD, and Michael H. McGuire, MD, thought it was Paget’s disease. “This is based on the enlarged size of the bone and coarsened trabeculae without any other systemic symptoms in an older individual,” said Dr. Helmers, while Dr. McGuire relied on his training to make the diagnosis of “Paget’s disease of bone affecting the middle phalanx of the long finger. The reason is that Henry J. Mankin, MD, taught me so 30 years ago.”

According to Drs. Albanese and Levinsohn, the actual diagnosis was Paget’s disease. “Typically, Paget’s Disease extends to the subarticular bone and shows thickening of the trabeculae and cortix as is present in this case. Nonossifying fibroma is unlikely because that entity does not ossify in a lacey pattern as is seen in this patient,” said Dr. Albanese.

Watch next month’s AAOS Now for another challenge.